Does a voucher program improve reproductive health service delivery and access in Kenya? Health policies, systems and management

BMC Health Services Research, Volume 15, No. 1, Year 2015

Interpretation

Background: Current assessments on Output-Based Aid (OBA) programs have paid limited attention to the experiences and perceptions of the healthcare providers and facility managers. This study examines the knowledge, attitudes, and experiences of healthcare providers and facility managers in the Kenya reproductive health output-based approach voucher program. Methods: A total of 69 in-depth interviews with healthcare providers and facility managers in 30 voucher accredited facilities were conducted. The study hypothesized that a voucher program would be associated with improvements in reproductive health service provision. Data were transcribed and analyzed by adopting a thematic framework analysis approach. A combination of inductive and deductive analysis was conducted based on previous research and project documents. Results: Facility managers and providers viewed the RH-OBA program as a feasible system for increasing service utilization and improving quality of care. Perceived benefits of the program included stimulation of competition between facilities and capital investment in most facilities. Awareness of family planning (FP) and gender-based violence (GBV) recovery services voucher, however, remained lower than the maternal health voucher service. Relations between the voucher management agency and accredited facilities as well as existing health systems challenges affect program functions. Conclusions: Public and private sector healthcare providers and facility managers perceive value in the voucher program as a healthcare financing model. They recognize that it has the potential to significantly increase demand for reproductive health services, improve quality of care and reduce inequities in the use of reproductive health services. To improve program functioning going forward, there is need to ensure the benefit package and criteria for beneficiary identification are well understood and that the public facilities are permitted greater autonomy to utilize revenue generated from the voucher program. The paper draws from qualitative data collected in 2010 as part of a larger quasi-experimental design aimed at evaluating the impact of the Kenyan OBA voucher scheme on increasing access to, and quality of, selected reproductive health (RH) services [22]. These data were derived from in-depth interviews (IDIs) with facility managers and healthcare providers from program sites in Kitui, Kiambu, Nairobi, and Kisumu. The IDIs took place alongside quantitative health facility assessments and population surveys aimed to measure the impact of the voucher program on access to health facilities and quality of services. Details of the larger evaluation and population surveys are discussed elsewhere [22]. The in-depth interviews aimed at gaining a deeper understanding of the perceptions and priorities of the health care providers regarding the voucher program. The interview guide was amended appropriately after pre- testing the tools. The in-depth interview guide focused specifically on: (i) technical knowledge of services offered using the voucher (ii) attitudes towards the voucher program iii) benefits and (iv) challenges of the voucher program, processes and the approach (v) and perceptions on program implementation. A total of 69 interviews with facility managers (n = 30) and healthcare providers (n = 39) working at 30 OBA accredited public, private, and faith-based facilities were conducted. These facilities were randomly sampled from the 54 voucher accredited facilities selected to participate in the first phase of the Kenya OBA program. We planned to interview the facility manager and healthcare providers working in the reproductive health units in the study facilities. However, in some facilities the facility managers were not present on the days of the interviews, therefore interviews were only conducted with the healthcare providers directly involved with reproductive health or maternal and child health services. Overall the study interviewed 46 females and 23 males from facilities ranging from dispensaries to hospitals. Table 1 presents the distribution and composition of healthcare providers and managers. Distribution and composition of service providers and managers The IDIs were tape recorded and transcribed into a Microsoft Word file. The transcribed texts were then transferred to NVIVO 10 qualitative data analysis software. Qualitative data analysis was done by two researchers to ensure reliability in the coding and results. The study hypothesized that a voucher program would improve reproductive health service delivery and access to target population. A combination of inductive and deductive analysis was conducted based on previous research and project documents. Following coding, a full list of themes was available for categorization within a hierarchical framework of main and sub-themes. The thematic framework was then systematically applied to all of the interview transcripts. We looked for patterns and associations of the themes and compared and contrasted within and between the providers and facility managers in different regions, sectors and levels. Ethical approval for the evaluation was granted by Population Council’s Institutional Review Board (IRB) No. 470 and Kenya Medical Research Institute (KEMRI) SCC 174. Informed consent was obtained prior to all interviews that were conducted in settings that ensured privacy and confidentiality. Participants were informed that they could withdraw from the research at any time. Data collectors were trained on ethical conduct.

AI Digest

Study Justification:

– The study aims to assess the experiences and perceptions of healthcare providers and facility managers in the Kenya reproductive health output-based approach voucher program.
– It seeks to understand the impact of the voucher program on reproductive health service provision.
– The study fills a gap in current assessments of Output-Based Aid (OBA) programs by focusing on the perspectives of healthcare providers and facility managers.

Study Highlights:

– Facility managers and providers view the RH-OBA program as a feasible system for increasing service utilization and improving quality of care.
– Perceived benefits of the program include stimulation of competition between facilities and capital investment in most facilities.
– Awareness of family planning (FP) and gender-based violence (GBV) recovery services voucher remains lower than the maternal health voucher service.
– Relations between the voucher management agency and accredited facilities, as well as existing health systems challenges, affect program functions.
– Public and private sector healthcare providers and facility managers perceive value in the voucher program as a healthcare financing model.

Study Recommendations:

– Ensure the benefit package and criteria for beneficiary identification are well understood.
– Permit public facilities greater autonomy to utilize revenue generated from the voucher program.
– Address existing health systems challenges to improve program functioning.

Key Role Players:

– Healthcare providers
– Facility managers
– Voucher management agency
– Policy makers
– Researchers/evaluators

Cost Items for Planning Recommendations:

– Training and capacity building for healthcare providers and facility managers
– Public awareness campaigns to increase knowledge of the voucher program
– Administrative costs for managing the voucher program
– Monitoring and evaluation activities to assess program impact
– Research and evaluation costs to gather data and assess program effectiveness

Strength of Evidence

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is based on qualitative data collected in 2010 as part of a larger quasi-experimental design. The study conducted in-depth interviews with healthcare providers and facility managers in 30 voucher accredited facilities in Kenya. The data were transcribed and analyzed using a thematic framework analysis approach. The study found that healthcare providers and facility managers perceived value in the voucher program as a healthcare financing model and recognized its potential to increase demand for reproductive health services and improve quality of care. However, the abstract does not provide information on the sample size, representativeness of the sample, or the specific findings of the study. To improve the strength of the evidence, the abstract could include more details on the methodology, such as the sampling strategy and the specific themes and findings from the analysis.

Abstract

The paper draws from qualitative data collected in 2010 as part of a larger quasi-experimental design aimed at evaluating the impact of the Kenyan OBA voucher scheme on increasing access to, and quality of, selected reproductive health (RH) services [22]. These data were derived from in-depth interviews (IDIs) with facility managers and healthcare providers from program sites in Kitui, Kiambu, Nairobi, and Kisumu. The IDIs took place alongside quantitative health facility assessments and population surveys aimed to measure the impact of the voucher program on access to health facilities and quality of services. Details of the larger evaluation and population surveys are discussed elsewhere [22]. The in-depth interviews aimed at gaining a deeper understanding of the perceptions and priorities of the health care providers regarding the voucher program. The interview guide was amended appropriately after pre- testing the tools. The in-depth interview guide focused specifically on: (i) technical knowledge of services offered using the voucher (ii) attitudes towards the voucher program iii) benefits and (iv) challenges of the voucher program, processes and the approach (v) and perceptions on program implementation. A total of 69 interviews with facility managers (n = 30) and healthcare providers (n = 39) working at 30 OBA accredited public, private, and faith-based facilities were conducted. These facilities were randomly sampled from the 54 voucher accredited facilities selected to participate in the first phase of the Kenya OBA program. We planned to interview the facility manager and healthcare providers working in the reproductive health units in the study facilities. However, in some facilities the facility managers were not present on the days of the interviews, therefore interviews were only conducted with the healthcare providers directly involved with reproductive health or maternal and child health services. Overall the study interviewed 46 females and 23 males from facilities ranging from dispensaries to hospitals. Table 1 presents the distribution and composition of healthcare providers and managers. Distribution and composition of service providers and managers The IDIs were tape recorded and transcribed into a Microsoft Word file. The transcribed texts were then transferred to NVIVO 10 qualitative data analysis software. Qualitative data analysis was done by two researchers to ensure reliability in the coding and results. The study hypothesized that a voucher program would improve reproductive health service delivery and access to target population. A combination of inductive and deductive analysis was conducted based on previous research and project documents. Following coding, a full list of themes was available for categorization within a hierarchical framework of main and sub-themes. The thematic framework was then systematically applied to all of the interview transcripts. We looked for patterns and associations of the themes and compared and contrasted within and between the providers and facility managers in different regions, sectors and levels. Ethical approval for the evaluation was granted by Population Council’s Institutional Review Board (IRB) No. 470 and Kenya Medical Research Institute (KEMRI) SCC 174. Informed consent was obtained prior to all interviews that were conducted in settings that ensured privacy and confidentiality. Participants were informed that they could withdraw from the research at any time. Data collectors were trained on ethical conduct.

Materials

N/A

Innovations

Based on the study, the recommendation to improve access to maternal health is to implement and expand the use of Output-Based Aid (OBA) voucher programs. This program provides financial incentives for healthcare providers to offer quality services and reduces financial barriers for women seeking maternal healthcare. The study found that healthcare providers and facility managers perceived the voucher program as a feasible system for increasing service utilization and improving the quality of care. It also has the potential to significantly increase demand for reproductive health services, improve quality of care, and reduce inequities in the use of reproductive health services.

To improve the functioning of the program, the study suggests ensuring that the benefit package and criteria for beneficiary identification are well understood. Additionally, public facilities should be given greater autonomy to utilize revenue generated from the voucher program. These recommendations can be used to develop innovations that focus on expanding and improving the implementation of OBA voucher programs in maternal health services. This could involve streamlining the processes, increasing awareness and understanding of the program among healthcare providers and facility managers, and addressing existing challenges in the health system that affect program functions.

AI Innovations Description

The recommendation that can be developed into an innovation to improve access to maternal health based on the study is to implement and expand the use of Output-Based Aid (OBA) voucher programs. The study found that healthcare providers and facility managers perceived the voucher program as a feasible system for increasing service utilization and improving the quality of care. The program was seen to have the potential to significantly increase demand for reproductive health services, improve quality of care, and reduce inequities in the use of reproductive health services.

To improve the functioning of the program, the study suggests ensuring that the benefit package and criteria for beneficiary identification are well understood. Additionally, public facilities should be given greater autonomy to utilize revenue generated from the voucher program. These recommendations can be used to develop an innovation that focuses on expanding and improving the implementation of OBA voucher programs in maternal health services. This could involve streamlining the processes, increasing awareness and understanding of the program among healthcare providers and facility managers, and addressing existing challenges in the health system that affect program functions.

Implementing and expanding OBA voucher programs can help improve access to maternal health by providing financial incentives for healthcare providers to offer quality services, increasing demand for reproductive health services, and reducing financial barriers for women seeking maternal healthcare.

AI Innovations Methodology

To simulate the impact of the main recommendations on improving access to maternal health, a methodology could be developed as follows:

1. Define the study population: Identify the target population for the simulation, such as pregnant women or women of reproductive age in a specific region or community.

2. Collect baseline data: Gather information on the current access to maternal health services, including utilization rates, quality of care, and financial barriers. This can be done through surveys, interviews, or existing data sources.

3. Develop a simulation model: Create a mathematical or computational model that incorporates the main recommendations of implementing and expanding OBA voucher programs. The model should consider factors such as the number of healthcare providers, facility capacity, voucher program criteria, and revenue allocation.

4. Input data and parameters: Input the collected baseline data into the simulation model, along with relevant parameters related to the OBA voucher program, such as the benefit package, beneficiary identification criteria, and autonomy of public facilities.

5. Run simulations: Run the simulation model multiple times, adjusting different parameters and scenarios to assess the potential impact of the recommendations. For example, simulate the effect of increasing awareness and understanding of the program among healthcare providers, or the impact of giving public facilities greater autonomy in utilizing voucher program revenue.

6. Analyze results: Analyze the simulation results to determine the potential impact of the recommendations on improving access to maternal health. Assess changes in service utilization rates, quality of care, and reduction in financial barriers.

7. Validate the simulation: Validate the simulation results by comparing them with real-world data or expert opinions. This can help ensure the accuracy and reliability of the simulation model.

8. Interpret findings: Interpret the findings of the simulation to understand the potential benefits and challenges of implementing the recommendations. Identify any additional factors or interventions that may be necessary to further improve access to maternal health.

9. Communicate results: Present the findings of the simulation in a clear and concise manner, highlighting the potential impact of the recommendations on improving access to maternal health. Share the results with relevant stakeholders, such as policymakers, healthcare providers, and facility managers, to inform decision-making and potential implementation of the recommendations.

By following this methodology, researchers can simulate the impact of the main recommendations on improving access to maternal health and provide valuable insights for policy and program development.

Author

Dima Health

Statistics:

Citations: 18

Identifiers:

DOI: 10.1186/s12913-015-0860-x

Research Areas:

Health System and Policy, Maternal Access, Maternal and Child Health, Quality of Care, Sexual and Reproductive Health, Social Determinants

Study Countries:

Kenya

Study Design:

Cross Sectional Study, Exploratory Study, Quasi Experimental Study

Study Approach:

Mixed-methods, Qualitative, Quantitative

Participants Gender:

Female